Work Entry

First Name

Last Name

Birthdate

/ /

Parent's First Name

Parent's Last Name

Home Phone

Mobile Phone

Address

How would you like the child's name to appear on the certificate?

How would you like the parent's names to appear on the certificate?

Will both parents be able to participate in the dedication event?

Please tell us how you heard about this event:

Weekend Handout Platform Announcement Emmanuel App Notification Informational Postcard Social Media Word of mouth Other

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